Perimetry testing http://www.oculist.net/downaton502/prof/ebook/duanes/pages/v3/v3c049.html http://www.opt.indiana.edu/riley/HomePage/Automated_Perimetry/Text_Auto_perm.

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Normal vision 60 superior 75 inferior 110 temporal 60 nasal

Kinetic perimetry-moving target from non-seeing to seeing

Static perimetry-

Comparison Fig. 7. Comparison of static and kinetic perimetry to detect shallow scotomas and determine the slope of the scotoma. A. Kinetic evaluation can clearly outline the normal visual field. B. Kinetic perimetry may miss shallow scotomas and poorly define the flat slope seen nasally. C. The edge of steeply sloped scotomas may be identified easily with kinetic perimetry, but the steepness of the slope may not be appreciated. D and E. Static perimetry readily detects shallow scotomas and can define the slope of both shallow and steep scotomas. (Aulhorn E, Harms H: Early visual field defects in glaucoma. In Leydecker W [ed]: Glaucoma Symposium. Basel: Karger, 1966.)

Types Confrontation fields Amsler grid- central 10-20 degrees Tangent screen most sensitive-picks up small scatomas, pt stands 1-2m from black screen, examiner uses wand Background illumination for Humphrey and Goldmann- 31.5 asb -less adaption time -less sensitive to background scatter of room light Perimetry should never be performed in a bright room

Goldmann- manual bowl, isopter definition, central and peripheral fields, both kinetic and static, but kinetic more common and defines and isopter, operator variability Scotomas are defined moving inward to out

The number and letter represent the intensity of the stimulus. A change of one number represents a 5-dB (0.5 log unit) change in intensity, and each letter represents a 1-dB (0.1 log unit) change in intensity (Table 2). The dynamic range of the Goldmann perimeter from the smallest/dimmest target (Ola) to the largest/brightest target (V4e) is greater than 4 log units, or a 10,000-fold change.

Humphrey-automated, static testing more common Standardized exam Statistical standardization for age, retinal sensitivity, and pupil size Threshold- dimmest target identified 50% of the time Target size = to gold man III=4mm2 but can be changed Test starts with quadrant threshold which determines the reference hill -5 from the reference number becomes diagnostic 5 degrees- mid 30s 5-30degrees-20s >30- teens to low 20s Bracketed numbers are the average of multiple tests at that spot Type of programs 30-2= 30 degree field test, 24-2- faster and easier 30-1 and 30-2 are interlocking patterns, separate they test 6 degrees of point separation, together 4.2 -1 have points on the x and y meridian lines

Single-Level Suprathreshold Test A stimulus that is 2 to 6 dB brighter (suprathreshold) than the expected hill of vision is used to test multiple locations in the visual field. Results are recorded simply as seen (normal) or not seen (defect). On the Humphrey perimeter, this is called the threshold-related strategy. Two-Level Suprathreshold Test These tests often are referred to as three-zone screening tests because the visual field is classified into three categories: normal, relative defect, and absolute defect. As in the single-level test, testing is performed initially with a mildly suprathreshold stimuli approximately 2 to 6 dB brighter than the expected threshold. Spots that are seen recorded as normal. If a spot is not seen, the brightest stimulus available for the apparatus is presented. If the brightest target is seen, a relative defect is recorded. If the brightest target is not seen, an absolute defect is recorded. One-Level Suprathreshold Screen With Quantification of Defects A one-level suprathreshold screen is performed. Then, thresholds are measured at the locations that are determined to be abnormal. Because defects within 6 dB of the expected hill of vision will not be identified, shallow defects and early progressive depression of the visual field may be missed. The test can be very time consuming if many points in the field of vision are abnormal. Full Threshold The full threshold strategy has been the most accurate way of evaluating and following the glaucomatous visual field, however, it is also the most time-consuming method (Fig. 19). The differential light threshold is determined at every point in the visual field using a 4-2 staircase or bracketing algorithm. In the 4-2 algorithm, testing starts with either a suprathreshold (seen) or an infrathreshold (not seen) stimulus. For a suprathreshold stimulus, the intensity of the stimulus is decreased in 4-dB steps until the stimulus is no longer seen (threshold is crossed). The stimulus intensity is then increased in 2-dB steps until the threshold is crossed a second and the stimulus is seen again (Fig. 20). The Humphrey perimeter uses the intensity of the last seen stimulus as threshold. Swedish Interactive Threshold Algorithm (SITA)- SITA uses artificial intelligence and computer modeling, incorporating probability models of normal and glaucomatous visual fields to provide more efficient testing of the visual field. Testing is interactive, using each response from a patient to help predict future responses. Information incorporated in the interactive testing includes comparison to reference fields in normal and glaucomatous eyes, normal age-corrected threshold values, patterns of glaucomatous damage, and multiple frequency of seeing curves in normal and abnormal states. At the end of the test, the threshold is recalculated based on all the available data. The time interval for each response is analyzed and those responses that were likely false are discarded.

Interpretation
Reliability: FP- click with no light, in full perimetry a sound is give before each spot, sometimes sound will occur without spot, trigger happy FN- fails to sign when a target is brighter than the know threshold at that spot, fatigue or inattentiveness, pts with scatoma will have high FN because they may move in and out of scatoma with slight movement Fixation loss- click with light in blind spot. >20% is alert Short-Term Fluctuation (SF) - It is simply an index of the consistency of the patients responses during the field testing. This value is obtained when ten (10) pre-selected points are tested twice and the difference, in decibels, of the patient's responses are compared. is usually between 1dB and 2dB during a given test period. There are two reasons for an abnormal Short-Term Fluctuation (SF), inattentive patient or a patient with a diseased visual system. LOW FLUCTUATION: < 1.5 dB NORMAL FLUCTUATION 1.5dB TO 2 dB MEDIUM FLUCTUATION >2 dB BUT < 3 dB HIGH FLUCTUATION >3 dB

2.) Grayscale - Is for the patients benefit; for their interpretation or understanding. Represents tested points and nontested intermediate points, which have been assigned values, interpolated from surrounding points. It tells the doctor nothing about the depth of a scotoma. 3.) TOTAL DEVIATION = (PATIENT'S RESPONSE) - (EXPECTED NORMAL) These are both represented in decibels and the difference between the two result in either a positive or negative decibel value. Positive means the patient performed above the expected and a negative means they performed that number of decibels below the expected. The plot just below this finding are graytone (symbols) which shows the statistical significance for a given test value. 4.) PATTERN DEVIATION = (TOTAL DEVIATION) + (OVERALL SENSITIVITY CHANGES) This plot is similar to the Total Deviation except the STATPAC attempts to adjust the analysis of the test results for any overall changes in the height of the measured hill of vision caused by say cloudy media, cataracts or small pupils. Hence, this numeric pattern deviation plot shows the deviation in decibels from the age-corrected normal values, adjusted for any shifts in overall sensitivity. The plot just below this finding are again graytone (symbols) which show the statistical significance of the results at each point. The darker the pattern (symbol) the more significant the deviation from the expected threshold. GLOBAL INDICES 1.) Mean Deviation or Defect (MD) - The (MD) is the mean difference in decibels between the "normal" expected hill of vision and the patient's hill of vision. if the deviation is significantly outside the norms, a P value will be given. Example: P< 0.5% means that less than 0.5% of the normal population showed a (MD) larger than the value found for this test. This index is a measure of overall depression, elevation of the field or significantly deep losses in one part of the field and not in others. 2.) Pattern Standard Deviation (PSD) - This is a measurement of the degree which the shape of the patient's measured field or hill of vision departs from the "NORMAL" age-corrected reference field model. The value is expressed in decibels and any value of 2dB or greater will have a (P) value next to it indicating the significance of the deviation. 3.) Corrected Pattern Standard Deviation (CPSD) This is a calculated measurement in decibels of how much the total shape of the patient's hill of vision deviates from the shape of the "NORMAL" hill of vision for the patient's age, after

being corrected for intra-test variability. In calculating the (CPSD) the STATPAC attempts to determine if the irregularities in the hill of vision are real by removing the short-term fluctuation (SF), which may mask a relative scotoma. Caveats - Each diopter of uncorrected refraction causes a 1.26 dB depression; near add is built into the perimeters software - If eye is not centered in the corrective lens, an artifactual scotoma from the lens rim may present - Pupils smaller than 2.5mm may cause generalized depression or highly dilated may exhibit peripheral distortions - Cataracts/media opacities- general depression - Ptosis- superior field defect, also large nose, overhanging brow - Learning curve- after 2nd test variability significantly drops - Fatigue/alertness. Prolonged testing may lead to decreased retinal sensitivity - Psychological factors: comfort, cooperation, motivation, stress, fear, concentration Why do patients hate the test: an efficient test will be performed with stimuli at or near threshold. Threshold is defined as the stimulus intensity seen 50% of the time. This means that during most of the test, the stimuli are so dim that patients are not sure whether they see the target